Rhinoliths are rarely reported in the literature despite the propensity observed particularly in children to insert foreign bodies into their nose and ears.
As the name suggests (‘lith’ means stone) they are hard objects, probably produced after a chronic inflammatory reaction activated by intranasal insertion of a foreign body, which acts as a nidus upon which mineral salts are deposited.1
The exact pathogenesis is unknown, but precipitating factors such as chronic inflammation, the presence of bacteria and obstruction of nasal secretions are thought to lead to the deposition of siderite, ferrihydrite or mineral salts such as calcium carbonate, calcium phosphate and magnesium phosphate around the nidus, resulting in calcareous concretions.1 2 4 6 7 8
The foreign body can be exogenous or endogenous. Exogenous bodies include buttons, stones, sand, peas, beads, fruit seeds and remnants of nasal tampons, while endogenous bodies include blood clots, epithelial debris, teeth and bone sequestra.1 8 9
The main entry route is via the anterior nares, with some suggestion of retronasal entry in the event of emesis.6
Rhinoliths are mainly found on the nasal cavity floor, but the frontal and maxillary sinuses have also been reported. They usually present unilaterally and are more often diagnosed in the third decade of life with a female predilection and rare manifestation in children.4 6 10
Bartholin first described rhinoliths in 1654 and the first chemical analysis was conducted by Axmann in 1829.4 11
Typical presenting symptoms are unilateral nasal obstruction, purulent nasal discharge, malodour and epistaxis, but crusting, localised pain, chronic headache, anosmia and swelling of the nose and surrounding face have been documented.4 6 10
Rhinoliths often remain asymptomatic or with only subtle signs for a long time.2 12
As our patient had no nasal symptoms, she did not attend an ENT specialist. Her main complaints were oral malodour and a year-long non-productive cough. She denied the insertion of any foreign body into her nose.
The first radiographic description of a rhinolith was presented by Macintyre in 1900.4 13
Postero-anterior plain x-ray, panoramic radiography and CT scan are the standard modalities for diagnosis. A CT scan is superior because of its ability to show small calcification deposits and detailed information on the contiguous structures, thus helping in the differential diagnosis. The commonly seen radiological features are central radiolucency (if there is an organic nidus) with surrounding radiopacity. There may be laminations and a corrugated surface.1 4 13 14 15
The CT scan of our patient showed the typical features of a rhinolith, as well as alteration in the anatomy of the lateral wall of the left nasal cavity. The level of origin of the left lower turbinate was dislocated superiorly along the entire length resulting in a higher inferior meatus. The bony and mucosal elements of the anterior third of the turbinate were atrophic. These findings, in conjunction with the absence of other anatomic malformations, suggested a very longstanding (probably since childhood) intranasal object resulting in altered outgrowth of the concha. The patient could not recall any acute or extended chronic nasal inflammation during her adult life.
Although clinical examination, endoscopy and CT scan are almost definitively diagnostic, in the differential diagnosis we should also consider osteoma, haemangioma, calcified nasal polyps, odontoma, impacted teeth, dermoid, chondrosarcoma, osteosarcoma, and tubeculous and syphilitic calcification.4 6 10
Complications reported in the literature include erosions/perforation of the septum/palate and recurrent inflammatory processes such as sinusitis, middle otitis or dacryocystitis.4 6
We assume that the anatomical alteration in our patient was a complication of the rhinolith without any impact on her well-being. Slight polypoid degeneration in the conchal mucosa was also detected.
Removal through the nostrils or endoscopically assisted removal are the most frequently used methods. The rhinolith can be removed as an intact object or after crushing to reduce its size. Lithotripsy could also be used to disintegrate the rhinolith. In rare complicated cases where the open route is necessary, lateral rhinotomy can be performed.1
- Rhinoliths are rare entities, with an estimated incidence of 1:10 000 otolaryngological outpatient examinations.
- The slow growth and subtle or absent symptoms demand a high index of suspicion so as to establish the diagnosis as soon as possible.